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Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 45-50

Frequency of complications during endodontic treatment: A survey among dentists of the town of Abidjan

1 Department of Conservative Dentistry and Endodontics, Félix Houphouët Boigny University, Abidjan, Côte d'Ivoire, West Africa
2 Department of Conservative Dentistry and Endodontics, Research Center of Health Sciences (UFR/SDS), Joseph KI-ZERBO University, Ouagadougou, Burkina Faso, West Africa

Date of Submission15-Apr-2019
Date of Decision13-May-2019
Date of Acceptance29-Jun-2019
Date of Web Publication27-Dec-2019

Correspondence Address:
Dr. Marie-Chantal Avoaka-Boni
Department of Conservative Dentistry and Endodontics, Félix Houphouët Boigny University, Abidjan, 22 BP 612, Abidjan 22, Côte d'Ivoire
West Africa
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_60_19

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Introduction: The aim of this study was to determine the frequency of the occurrence of endodontic complications according to the dentists of the town of Abidjan and to identify the various types encountered so as to prevent them.
Materials and Methods: This was a descriptive, cross-sectional prospective study. A survey form was randomly distributed to 150 dentists working in 128 private and public dental clinics in the town of Abidjan. The dentists were asked about the daily average number of patients treated, the frequency with which canal treatments were performed, and the complications encountered by dentists. The information collected was analyzed by means of EPI Info version 06.01 software.
Results: A total of 135 dentists replied to the questionnaires; nearly all of them (94.8%) stated that they had encountered complications during endodontic treatment. Canal wall damage represented 54.68% of the complications when generating the access cavity. Fracturing of instruments was a frequent occurrence during exploring the root canal (72.58%) and during canal shaping (55.47%). Overfill of the gutta-percha cone and/or the cement for obturation was the complication that occurs most with canal obturation (55.47%). Flare-up without swelling was often encountered postoperatively (81.49%).
Conclusion: Complications occurring during endodontic therapy remain a concern. Their prevention necessitates rigorous adhesion to the treatment protocols.

Keywords: Endodontic treatment, fractured instrument, mishaps, overfill, survey

How to cite this article:
Avoaka-Boni MC, Désiré Kaboré WA, Gnagne-Koffi YN, Djolé SX, Kouadio KT. Frequency of complications during endodontic treatment: A survey among dentists of the town of Abidjan. Saudi Endod J 2020;10:45-50

How to cite this URL:
Avoaka-Boni MC, Désiré Kaboré WA, Gnagne-Koffi YN, Djolé SX, Kouadio KT. Frequency of complications during endodontic treatment: A survey among dentists of the town of Abidjan. Saudi Endod J [serial online] 2020 [cited 2021 Nov 30];10:45-50. Available from: https://www.saudiendodj.com/text.asp?2020/10/1/45/274191

  Introduction Top

Endodontic treatment is a common procedure in dentistry that consists of elimination of organic tissues, infected debris, and pathogenic bacteria from the canal system by means of mechanical instrumentation associated with abundant disinfecting agents.[1] Its success is based on the capacity to manage all the compromising situations that can arise. Indeed, despite progress with its implementation, dentists may at any time be faced with complications, that is to say, situations that can hinder the normal sequence of events.[2] These complications can be preoperative (occurring during the various clinical procedures) or postoperative (occurring after the end of the treatment). When occur, these complications are a source of stress for the practitioner as they seek a solution, thus resulting in an additional effort to treat the patient. Frustration might occur if cannot be resolved.[3] Moreover, there appears to be an upsurge in these complications with, on the other hand, little data on how to take care of preoperative or postoperative complications in connection with endodontic treatments, which are frequently performed due to delayed consultations. In fact, they represent 60% of the daily procedures performed in Ivory Coast.[4] Moreover, when a failure occurs, 59% of the practitioners opt for renewed treatment that needs to allow the objectives of the initial treatment to be attained.[4] In light of this, studying the various confluences of events that can impede this is warranted as these can have an impact on the success rate of endodontic treatments. This is why the general objective of this work is to record the frequency of endodontic complications according to the dentists of the city of Abidjan, and to identify the various types encountered, in order to prevent them.

  Materials and Methods Top

Ethical considerations

The research protocol of this study was approved on December 28, 2015, by the National Ethics Committee for Life Sciences and Health of Ivory Coast (US DPT OF REGISTRATION #2: IRB000111917). The approval number is N°: 09015/CNESVS.

Selection of the dentists

This was a descriptive, cross-sectional prospective study. Based on the list provided by the National Board of Dentists of Ivory Coast, 150 dentists were randomly selected independently of their gender from 128 private and public dental clinics (on average, there are 612 dentists in the town of Abidjan). This sample is statistically representative of all of the dentists of the town of Abidjan, and it was calculated according to the formula of Schwartz.[5] Dentists practicing in both the private and the public sectors of ten municipalities of the town of Abidjan and suburbs were included in this sample. These sites were chosen because they have a high concentration of practitioners, representative of all of the dentists operating in Ivory Coast. Dentists in training were not included.

Execution of the survey

A form for collection of the data devised for the requirements of this study allowed relevant information to be collected such as particulars of a general nature (type of practice, and number of years in practice), number of patients received on average per day, frequency with which root canal treatments are performed, and complications encountered. A presurvey (pilot) was carried out among ten dentists so as to evaluate how well the questions of the survey are understood and the level of difficulty with filling out the form. Analysis of the questionnaires collected during this presurvey allowed correction and reorganization of the sections that could lead to confusion so as to remove all ambiguity. We then proceeded with a survey by self-administration of the questionnaires: the survey form was dropped off at the dental clinics by a surveyor and filled out by the dentist in the absence of the former. The survey took place over 6 months from January 2016 to June 2016. The information collected was analyzed by means of EPI-INFO version 06.01 software (Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America). The results obtained are presented as a table, using Excel and Word 2013 software in Windows XP professional.

  Results Top

At the end of the preinvestigation, one dentist declared to be an endodontic graduate. This concept was therefore integrated into the final survey form. Of 150 dentists questioned, 135 replied to the questionnaires, thus amounting to a participation rate of 90%. The results derived from the group of 135 practitioners who ultimately participated in the survey are presented in [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6].
Table 1: The average number of endodontic treatments performed per month by 135 dentists

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Table 2: The average number of endodontic complications (cases) encountered per month by 128 dentists (7 dentists had no complications)

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Table 3: Distribution of the complications encountered during endodontic access cavity preparation performed at 128 dental clinics

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Table 4: Distribution of the complications encountered during exploring the root canal at 128 dental clinics

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Table 5: Types of complications encountered during canal shaping at 128 dental clinics

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Table 6: Types of complications associated with canal obturation performed at 128 dental clinics

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Characteristics of the sample

The distribution according to the type of practice allowed us to show that all years of experience were represented, with a sex ratio of 2.5. The majority of the practitioners (61.19%) were in private sector and 39.25% were in public. They were mostly trained in Ivory Coast (88.89%), France (11.90%), and Senegal (2.80%). There were 9 (6.77%) who declared to be an endodontic graduate. However, they do not have an exclusive practice in endodontics and have been therefore assimilated to the entire group of dentists. The number of endodontic treatments performed by dentists was between 6 and 10 per month that represent 39.25% [Table 1].

Frequency of complications

Of 135 dentists who participated in the study, nearly most of them (94.8%) stated that they had encountered complications in the course of endodontic treatment [Table 2].

Complications encountered preoperatively

The practitioners encountered different types of complications when undertaking the endodontic access cavity procedures, exploring the root canal, shaping of the canal, or during obturation of the canal. Damage (gouging) of the cavity walls (54.68%) was the most common complication encountered while generating the access cavity [Table 3]. Fracturing of instruments (72.58%) was a frequent occurrence when exploring the root canal [Table 4] and during the shaping of the canal (55.47%) [Table 5]. Overfilling with gutta-percha cone and/or cement (55.47%) was the most complication occurred during canal obturation [Table 6].

Complications encountered postoperatively

A flare-up was the most often encountered complication postoperatively. Painful consequences without swelling accounted for 81.49% of the postoperative complications. Postoperative pain with swelling accounted for 1.61% of the postoperative complications. Facial subcutaneous paresthesia and emphysema accounted for 4.83% and 1.61% of the postoperative complications, respectively.

  Discussion Top

The data in Ivory Coast show that endodontic emergencies constitute the foremost reason for a consultation in odontology. In 2001, Avoaka-Boni et al. showed in a study in Abidjan that endodontic treatment is the daily procedure performed most often by dentists.[4] The technique of manual preparation by alternation of K-file and H-file is the most used. However, as in Dakar (Senegal), most practitioners (62%) use the single-cone adjusted filling technique, and only 30% of them use lateral compaction technique with gutta-percha.[6],[7] This highlights the need for awareness of the exclusive use of compressive sealing techniques that ensure the sealing tightness and therefore the success of treatment.

The present study remains in agreement with these earlier studies as it shows that the majority of the practitioners (39.25%) performed between 6 and 10 endodontic treatments per month. This nonetheless represents a high rate of this therapeutic procedure being performed. Of the 135 dentist surveyed, 128 (or 94.81%) revealed that they had encountered cases involving complications during their practice. No correlation could be established between the number of endodontic treatments and the number of complications that occurred.

This study sought to determine the type of complications most often encountered by the practitioners. These could be grouped as fractures of the tooth or of instruments, perforations associated with a hemorrhage, and overinstrumentation and overobturation associated with pain. More than half of the practitioners (54.68%) had damaged (gouging) the walls of the access cavity, which can lead to cracking of the crown or the creation of a stubborn. Quite often, shaping of the canal becomes difficult due to such stubborn. Indeed, generating the access cavity requires a very thorough knowledge of the tooth anatomy and its variations. The success of endodontic treatment is tightly linked with the quality of this cavity. When it is done properly, the transition between the access cavity and the pulp chamber is done without stubborn and the progression of instruments without constraints or interference.[8] Accidental ledges are usually situated at the level of the maximal canal curvature, in continuity with the main axis of the canal.[9] Ledges close to the apical area are particularly difficult to manage. They can make the opening of an access cavity and its homogenization very laborious.

This study found that instrumental fractures are a common occurrence at all stages of the treatment, and nearly ¾ of the practitioners encounter this during access cavity preparation. Unfortunately, instrument fracturing is not a rare occurrence. For nickel-titanium instruments, the incidence of fracturing is approximately 5%, even with experienced practitioners.[10] The rate of instrument fracturing found in the literature varies from 1% to 6%, and fragments are left in the place for 3.3%[11] with potential contamination that has the ability to affect the healing process.[12] Corrosion due to endodontic solvents and weakening caused by repetitive thermal cycles of sterilization are the factors to be taken into account.[13],[14] During root canal treatment, the practitioner performs multiple passes with the endodontic instruments. It is, therefore, paramount that they have been trained to use various systems for canal shaping that are used in a dental practice. Since experienced practitioners have a considerably reduced risk of fracture,[15] continued professional development and dental experience are the main ways to prevent instrument fracturing.[16],[17]

There are numerous complications when it comes to canal shaping. Indeed, the survey revealed the formation of stubborn for 63.29% of the practitioners, instrumental fracturing for 55.7%, parietal perforation for 15.63%, or apical transportation for 14.07% of them.

Two studies assessed radiographs of the root canal-treated teeth for procedural errors in dental hospitals in Pakistan. Akhtar et al. identified the most common errors done by newly graduate dentists (interns) as apical transportation (12% of procedural errors), apical perforation (5%), instrument separation (4%), and perforation during access (3%),[18] while Yousuf et al. identified the most common errors to be overfilling (22.7%), underfilling (8.9%), instrument separation (0.9%), and apical transportation (0.4%).[19] Indeed, overinstrumentation of the apical region can give rise to an apical rip, also referred to as “zipping.” A stripping perforation happens particularly at the level of the distal wall of the mesial roots of mandibular molars, which have an average thickness of approximately 1 mm, thus partly explaining the frequency of complications with these teeth.[20] Overfill of obturation materials is the most frequent issue with canal obturation (55.47%). It is well established that endodontic materials should be limited to root canals without extension to the periapical tissues during root canal treatment. However, overextension of these materials can occur accidentally following overinstrumentation or perforation of root canals, thereby resulting in the spread of disinfecting agents, solvents, or obturation materials into the periradicular tissue. Accidental overextension of the filling material during endodontic treatment can lead to mechanical and chemical irritation of the periapex.[21] Calcific pulp degeneration, which is a fairly common pathophysiological formation, can complicate access opening for root canal treatment that might resulted in canal aberration, internal or external transport of the apical foramen, and lateral perforation or perforation of the pulp floor.[22] Irrigation with sodium hypochlorite and ethylenediaminetetraacetic acid can help in dissolving calcifications, and ultrasonic instruments can mechanically help in removing calcifications.[23] However, teeth with canal calcifications may require root resection using a surgical method if cannot be opened.[23]

Sodium hypochlorite is the irrigation solution of choice for most endodontist, and it is considered as the primary irrigant.[24] A 2.5% sodium hypochlorite had maximum pulp tissue dissolving capacity in vitro.[25] However, when it comes into contact with periapical tissues, it can lead to complications ranging from slight discomfort to serious tissue lesions, such as hematomas and hemato-emphysema.[3] It is characterized by a swelling, and the consequences are sometimes serious and even life-threatening.[26] Facial subcutaneous emphysema was reported in this study. In general, accidental extrusion of sodium hypochlorite beyond the periapex during irrigation is a rare occurrence.

The study reported some complications due to arsenic dioxide. Its toxicity can cause gingivitis and osteonecrosis. Its use has been prohibited in Europe and the United States for decades, but some dentists still use it the town of Abidjan. A clearer message must be given to all dental practitioners against the use of arsenic in modern endodontic treatment.[27]

Preoperative pain was encountered as a complication by a significant proportion (42.97%) of the dentists of the town of Abidjan. These situations resulted in delaying the canal obturation stage. A case of an endodontic instrument being swallowed was reported in the course of canal shaping (0.79%). One reason for this type of accident may be the lack of a suitable clinical area to undertake the root canal treatment (rubber dam isolation), a hazard that was also highlighted by Avoaka-Boni et al. in a prior study.[28]

Hemorrhages and separated instrument during obturation were noted by some practitioners. This would be due to the use of the Lentulo instrument to deliver the sealer cement despite the inefficiency of the techniques. The need for increased awareness of good practices is very important.

Various symptomatologies have been reported postoperatively, while not directly linked to a complication that occurred during the endodontic procedure. Thus, the majority of the practitioners who were questioned, that is to say, 81.49% indicated having had patients coming back due to persistent postoperative pain. Despite adherence to best practice guidelines during endodontic procedures, complications such as pain and/or swelling can occur between sessions. These emergencies are adverse and troublesome events that need to be resolved immediately.[28] For numerous patients, flare-ups are an unpleasant experience that gives rise to doubts regarding the skills of the dentist.[29] Nevertheless, fear of procedural accidents should not dissuade practitioners from undertaking root canal treatments. Experienced clinicians should use their knowledge, skill, clinical common sense, experience, and awareness of their own limitations to minimize accidents.[30]

  Conclusion Top

Endodontic treatment is a procedure that requires a great deal of attention when carrying out its various stages. The complexity and the specificity of this therapeutic procedure mean that dentists face complications at all stages of its execution. This study showed that nearly all of the dentists interviewed had encountered complications during endodontic treatment. Therefore, incidents and accidents during endodontic treatment remain a concern. Such complications can be prevented by closely adhering to best-practice treatment protocols and experience.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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